Provider Demographics
NPI:1194379321
Name:FODERARO, ELIZABETH ANN (MT)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANN
Last Name:FODERARO
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28604 INTERSTATE 10 W UNIT 4
Mailing Address - Street 2:
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006-9115
Mailing Address - Country:US
Mailing Address - Phone:830-431-0773
Mailing Address - Fax:830-265-4053
Practice Address - Street 1:28604 INTERSTATE 10 W UNIT 4
Practice Address - Street 2:
Practice Address - City:BOERNE
Practice Address - State:TX
Practice Address - Zip Code:78006-9115
Practice Address - Country:US
Practice Address - Phone:830-431-0773
Practice Address - Fax:830-265-4053
Is Sole Proprietor?:No
Enumeration Date:2019-07-25
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT003468225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist